In Covid times, doctors face dilemma

BENGALURU: If there is one ventilator and two critical Covid-19 patients in need, who would the doctor give it to? Is the decision based on who is more likely to survive, or who arrived first at the hospital? The person who arrived first may be affluent and have travelled by car, while the other may be poor and walked from the bus stop. This is just one of hundreds of ethical dilemmas doctors face when making administrative and clinical decisions.

“How do we allocate resources separately for Covid and non-Covid services? If we take resources from non-Covid services and give it to another, won’t patients be affected? For example, a limited number of dialysis machines is available, but Covid patients with kidney problems need separate ones. Allocating machines for them reduces the number of machines available for non-Covid patients,” said Dr Sanjiv Lewin, chief of medical services, St John’s Medical College Hospital.

He pointed out that hospitals with limited resources have to make a choice between saving lives and reducing transmission. Do they test only those who are symptomatic and save lives, or test all by stretching meagre resources, to reduce transmission?“Should Covid surcharges such as cost of PPE be levied on all patients or only on Covid ones? If we charge only corona patients, the bill would be too high to bear,” Dr Lewin said. 

Patients with non-Covid diseases are getting neglected, with increased resource allocation for Covid, observed Dr Suman Sagar GL, critical care specialist at People Tree Hospital.“Though we have demarcated Covid and non-Covid ICUs, owing to high caseload and pressure for beds, at times Covid patients have to occupy non-Covid ICU beds. Those who are well-connected and have clout are able to secure a hospital bed easily, as opposed to a needy person,” Dr Sagar said. 

Corporate hospitals with more capital have, however, been able to prepare themselves during the lockdown for the surge in corona cases in the city and state which started in July, and were saved from such ethical dilemmas to an extent. “We slowed down elective surgeries and rescheduled them so that ventilators and ICU beds were available for Covid patients.

The dilemma appears when unplanned, emergency non-Covid cases show up. We have our limits and are careful as we reach 99 per cent. We keep a couple of beds as buffer for patients in our general ward, whose condition may suddenly become critical,” said Dr Sunil Karanth, chairman, critical care services, Manipal Hospitals. Though they try not to refuse too many patients, they advise against referrals from other hospitals if the patient’s condition does not require it.

While this hospital has been comfortable resource-wise so far, the management is apprehensive of what could happen if there is a surge in corona cases. There are three categories of patients -- the dying, the sick but who can survive, and the stable. They are concentrating on getting immediate first-aid for the second category of patients, as they are most likely to benefit. 

“We also make shared decisions by consulting the family on whether the patient should be put on ventilator or not, as in some cases the ventilator may not help. Our bed booking and discharge process has become more streamlined. We have a waiting list of patients and coordinate with doctors from other hospitals, to check if a patient needs to be shifted,” Dr Karanth said, adding that they share resources with their other branches.